Concussion in Youth Athletes: Where Are We Heading? Thomas L. Pommering, D.O. Division Chief, NCH Sports Medicine Assistant Clinical Professor, Departments of Pediatrics and Family Medicine The Ohio State University College of Medicine
The definition didn t change
Classification of Concussion No unanimous consensus Previously: Simple vs. Complex) 80-90% of concussions resolve in a short period (7-10 d), although this recovery time may be longer in children & adolescents
Concussion: Why should we care? 30 million children and adolescents participate in sports in the US each year Silent epidemic Up to 3.8 million sports-related concussions each yr 300,000 sports-related TBI s resulting in LOC (10%) Over half go unreported
CONCUSSIONS ARE UNDER- REPORTED IN HS ATHLETES (McCrea M, et al. Clin J Sport Med, 2003) Only 47% of high school athletes reported their concussion Most common reasons for not reporting: Not serious enough to warrant medical attention (66%) Didn t want to be withheld from play (41%) Lack of awareness of probable concussion (36%)
COMMON SIGNS OF CONCUSSION Vacant stare glassy eyed Poor coordination or balance Confused LOC (<10%) Inappropriate behavior Unusual emotions Slow to answer or follow instructions Personality change Disoriented Unusually quiet Motor phenomena: Short lived seizure Tonic posturing S/S of concussion may be progressive and evolving
COMMON SYMPTOMS OF CONCUSSION Headache Difficulty w/ memory Dizziness/vertigo Generalized weakness Numbness/tingling Vision changes Poor concentration seeing stars or lights foggy or dazed Phonophobia Photophobia Depressed mood Nervousness/anxiety Insomnia/hypersomnia Emotional lability Nausea/vomiting Tinnitus Fatigue
Do Cumulative Effects Exist? Depression (Guskiewicz KM, et al. Med Sci Sports Exec, 2007) Memory and concentration problems Delayed recovery with subsequent concussions Increased susceptibility for additional concussions Chronic Traumatic Encephalopathy (CTE) Apolipoprotein (APOE) genotype (Tierney, et al. Clin J Sport Med, 2010) all 4 alleles (rare) 10 x more likely to report prev concussion Promotor allele only 8.4 x more likely to report prev concussions
Cumulative Effects cont d For HS and College Athletes with > 3 concussions: More severe on field presentation of s/s (Collins et al, J Neurosurg, 2002) More likely to report HA s at baseline (Register-Mahalik et al., Clin J Sport Med 2007) More vulnerable to subsequent injury than those w/no concussion hx (Iverson et al., Brain Inj, 2004) 3 x more likely to sustain additional injury (Guskiewisz et al., JAMA 2003) Had prolonged recovery (Collie et al., B J Sports Med 2006; Couvassin et al., J Athl Train 2008; Slobounov et al., Neurosurg 2007)
Cumulative Effects cont d For Collegiate Athletes with > 2 concussions: Delayed recovery of verbal memory and Rxn time (Couvassin et al., J Athl Train 2008) Independently predicted long-term deficits in executive function, processing speed and self-reported symptom severity (Collins et al., JAMA 1999)
What do you do when faced with a young athlete with a possible concussion?
NO Same Day RTP for Athletes < 18 y/o
SECOND IMPACT SYNDROME (SIS) Sanders R, Harbaugh R. JAMA, 1984) (McCrory, P. Neurology, 1998) (Cantu, RC. Clin Sports Med, 1998) Occurs when an athlete sustains a second head trauma before the original head injury or concussion has healed leading to Acute loss of autoregulation of cerebral blood flow Diffuse Brain swelling Brain herniation! Mortality = 50% / Morbidity = 100%
SECOND IMPACT SYNDROME (SIS) (Bey, T West J Med, 2009) (Mueller & Cantu; National Center for Catastrophic Injury Research http://www.unc.edu/depts/nccsi/) 1980-1993: 35 cases 2008: 5 cases Takes about 2-5 min for the herniation to occur (much faster than for an epidural hematoma ) S/S: Loss of EOM Dilated/fixed pupils Respiratory distress SIS is has almost exclusively been documented in children and teens!!! Best Tx is PREVENTION
What Current Tools are at our Disposal? Become educated - parents, coaches, league administrators, officials, athletic trainers, physicians Seek advice and care from medical professionals who have expertise in concussion management Sideline assessment tools (training room or office setting) SCAT BESS Neuropsychological Testing (NP)
BESS (Balance Error Scoring System) (Iverson et al., Brain Injury, 2008) Rapid, easy to admin and cheap Measure postural stability (balance) a sensitive indicator of brain injury Requires AIREX foam pad ($60) Confounders: ankle instability, fatigue, slight practice effect BESS testing most useful when interpreted in conjunction with other testing ( SCAT2 and NP)
Role of Neuropsychological (NP) or Neurocognitive Testing Allows us to objectively measure cognitive function as it relates to brain injury Pen and paper tests (Trail making Test - 10 min) Computer / web-based systems (10-25 min) Formal NP testing with a trained and certified Neuropsychologist (4-6 hrs)
Computerized NP Testing COGSPORT IMPACT ANAM HEADMINDER
Computerized NP Testing: Advantages Disadvantages Relatively quick and easy Measure verbal and visual memory, processing speed and reaction time Most effective when baseline testing can be done in conjunction with post-injury testing Useful and reliable clinical tool if administered and interpreted properly and has value to the athlete, coach and parent Cost: $10-35 per test.limited Availability Proprietary interests do exist. (McKeag: JAMA, 2003) Perception that they are the Cat s Meow & are the absolute Standard of Care Baseline testing is not always feasible Practice effect
RETURN TO PLAY (RTP) Cornerstone of management is physical and cognitive rest Athletes must be asymptomatic for at least 24 hrs before they re permitted to start a supervised progression
RTP Guidelines
Modifying Factors in the Mgmt of Concussion Note: Gender was left off of this list at the time of publication, though evidence points toward increased risk in females d/t: - Smaller head mass - Weaker neck mm - More likely to report symptoms than males
What s on the Horizon in Terms of Future Concussion Management (Davis et al., BJSM, 2009) Structural Imaging CT, MRI, diffusion tensor imaging Functional Imaging fmri, PET, brain SPECT Spectroscopy MR spectroscopy (MRS), Near infrared spectroscopy (NIRS) Balance testing BESS, Sensory Organizational Test (SOT), gait testing, virtual reality) Electrophysiological tests EEG, evoked potentials (EK), event related potentials (ERP s), magneticoencephalography (MEG), HR variability Genetics APoE4, channelopathies Blood markers S100, neuron-specific enolase, cleaved Tau protein, glutamate
Prevention Can Protective Equipment Make a Difference? (Benson et al., BJSM, 2009) 1. Helmets: reduces injury risk in cycling, skiing and snowboarding; but effect on concussion was nonconclusive!? 2. Mouthguards: No strong evidence to reduce concussion risk, but they re good for the teeth! 3. Face shields: No strong evidence to reduce concussion risk 4. Full face protection in hockey can reduce concussion severity (time loss from competition)
Football helmets FRIEND OR FOE:! designed to prevent head bleeds and skull fx s, PERIOD
THE END THANKS!